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Plantar Fasciosis or Lateral Plantar Nerve Pain

9/18/2014

5 Comments

 
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Plantar Fasciosis can be a very difficult condition to treat because of the intricate anatomy of the foot and ankle complex. To complicate issues, we now know that many lower quarter problems root from lumbopelvic and hip dysfunction as well. In previous posts, TSPT has done a literature review of the condition as well as talked about new treatment methods regarding plantar fasciosis. In these posts, one aspect of management we did not discuss in depth is assessing for neuropathic pain. From my clinical experiences and the experiences of my colleagues at the Harris Health System, many patients with plantar fasciosis have positive neural provocation tests for the distal branches of the tibial nerve.        

Anatomy Review
After the tibial nerve passes around the medial malleolus, it splits into three distal branches: the medial plantar nerve, lateral plantar nerve, and medial calcaneal branch. Specifically, the lateral plantar nerve innervates the fifth and lateral 1/2 of the fourth toes and provides motor input to many of the intrinsic foot muscles. The nerve passes laterally across the foot and splits between the flexor digitorum brevis and quadratus plantae.   

Assessment
To assess for tibial nerve adverse neural tension, have the patient lie supine. Passively extend the toes, dorsiflex and evert the ankle. This combined movement place a stress across the tibial nerve and its distal branches. Ask the patient if this position changes their primary symptoms (better, worse, or the same). Next, passively perform a straight leg raise maintaining the foot and ankle components. If this position recreates their primary symptoms, they have positive neural tension in the tibial nerve* (remember to test bilaterally as well). To further assess the tibial nerve, adduct and internally rotate the lower extremity. If the test is positive, appropriate treatment options include nerve sliders, tensioners, and manual therapy.   

*When performing a straight leg raise, you are changing the hip component. No musculoskeletal structure courses from the hip to the ankle, so if symptoms change it must be the nervous system that is being assessed.  

Conclusion
-Lateral plantar nerve pain can be a contributing factor to plantar fasciosis pain. 
-By performing the proper assessment (discussed above), you can identify if neural tension is part of your patient's symptoms.
-Do not underestimate the impact of the peripheral nervous system in musculoskeletal dysfunction. 
Lower Extremity Peripheral Nerve Testing
[Video taken from TSPT Insider Access Library- subscribe to learn other advanced assessments!]
Author: Jim Heafner PT, DPT, OCS is one of the founders of The Student Physical Therapist. He is owner of Heafner Health Physical Therapy in Boulder, Colorado.  

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5 Comments

Barefoot Running: Review of the History of the Barefoot Movement by The Gait Guys

5/26/2014

1 Comment

 
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The Gait Guys recently re-posted one of their original articles, and it occurred at the beginning of the barefoot running trend. As you'll read in the article, barefoot running had advocates decades before the "vibram five-finger movement." There are many reasons for this as barefoot running has been shown to improve sensory feedback in the feet and foot intrinsic muscle control. There have been some studies that have shown decreased force translation into the lower extremity due to the development of a more efficient gait pattern. Since this article was written, quite a bit more research has been done on the topic. As you may be aware, while barefoot running may be an excellent form of running for some, it is not true for others. Some are born with anatomical foot abnormalities that make barefoot running unrealistic. With a slight change in foot structure, the majority of the force goes through one area which can lead to fractures or other overuse injuries. Even so, the article is definitely worth reading as it details how humans have used their feet over time and the response the neurological and dermatological systems have when exposed to the ground without a medium.

1 Comment

ATFL Sprain or Neural Tension

3/5/2014

2 Comments

 
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Following a lateral ankle injury, a patient often presents with swelling, pain, decreased ROM, an acute joint dysfunction, and decreased proprioception in the foot and ankle. Depending on the severity of the injury, these symptoms usually begin to improve within a matter of weeks. However, occasionally symptoms persists despite doing all the proper things during your treatment sessions. 

Most commonly, if a lateral ankle injury occurs the Anterior Talofibular Ligament (ATFL) will be stressed and injured. The mechanism of injury stressing the ligament typically includes adduction and traction of the talus on a plantarflexed and inverted foot. What many individuals fail to consider is the close interaction between the Intermediate Dorsal Cutaneous Nerve (a branch of the superficial peroneal nerve) and ATFL. The Intermediate Dorsal Cutaneous Nerve courses just superior to the ATFL and can also undergo a significant amount of stress during a lateral ankle inversion injury. The nerve is purely sensory and provides sensation to the dorsal aspect of the foot. When the nerve has been irritated, common clinical findings include pain, paresthesia, and a + Tinel's Sign. 

To check for neural tension in the superficial peroneal nerve (you cannot solely tease out the Intermediate Dorsal Cutaneous Nerve), have the patient lie in supine. Bring the affected foot and ankle into plantar flexion and inversion. Next, perform a straight leg raise on the affected limb while maintaining the foot in PF and Inversion. If pain increases, this is positive neural tension. It is very important to perform the straight leg raise because if you only perform PF and Inversion, pain could be coming from either the ligamentous injury or neural tension. You must further tension the nerve proximally.

One should be quick to point out that neural tension may be present, but it is not always the cause of a person's symptoms. In order for the neural tension to be considered relevant adverse neutral tension it must fulfill 3 criteria:
1) Does the test reproduce their pain?
2) Is there a side to side difference?
3) Does the pain change by moving a distant component? 

Assessing neural tension is one quality that differentiates the novice clinician from an expert. Next time you see a lateral ankle injury, consider the interaction between the Anterior Talofibular Ligament and the Superficial Peroneal Nerve.
   

2 Comments

Quick Gait Assessment

7/27/2013

1 Comment

 
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In the clinic, we often only have the length of the gym to analyze a patient's gait pattern. They patient may walk back and forth 2-3 times, giving you a total of 30 seconds to 1 minute to fully assess their pattern and recognize any deviations. 

In this post from the Physioblogger, he discusses his Quick Gait Assessment. His assessment includes looking at the feet, hips, and trunk. He starts at the feet and works cephalad. Beginning at the feet, he assesses heel to toe progression and the amount of pronation/supination. Next at the hips, he analyzes frontal plane motion and the amount of pelvic sway. Finally in the thoracic region, quick notes are made on the amount of arm swing and trunk stiffness.

Important points:
-No diagnosis is made during the gait assessment. Formulating hypotheses as to why a deviation is present is fine, but do not make definitive judgements as to why deviations are occurring. It is simply an observation. 
-Always remember a patient's injury, mechanism, lifestyle. What structures are involved? How can this injury/ their lifestyle impact the gait cycle?
-If possible, videotape your patients! Watch their gait patterns after they are gone. Take a few notes, perform the appropriate tests and measure, and act accordingly! 

Everyone has a different system they use for their quick gait assessment. Having a consistent method and practicing that method is important to your success as a therapist. Remember, we are movement analysis specialists. 

1 Comment

Review of the stages of Gait at the Hip, Knee, and Ankle: 

10/15/2012

5 Comments

 

Because we all strive to be movement analysis specialists, a little gait mechanics review never hurts. 

Each graph breaks down the ROM requirements, muscle, torque demand, and functional significance as described by Rancho Los Amigos.

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All graphs courtesy of Saint Louis University student, class '12. 
5 Comments

Plantar Fasciopathy 

10/13/2012

1 Comment

 
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     It has been estimated that Plantar Fasciitis occurs in approximately 2 million people and can account for between 8% and 15% of all foot pain complaints. While the term "-itis" is often associated with inflammation, there is growing evidence that there might not be an inflammatory state, but rather a degenerative process occurring in the plantar fascia. Because of this growing belief, authors are saying a more appropriate term would be "plantar fasciopathy" or "plantar heel pain."  
    
    Plantar heel pain is best described as a sharp pain in the patient's rear foot that is worse in the morning (usually the first step out of bed) and at the beginning of a weight bearing activities. The pain typically lessens with continued activity, but often increases toward the end of the day. Individuals most susceptible to developing heel pain are middle-aged women, obese individuals, athletes, and runners. Clinically, you will see excessive pronation and a depressed longitudinal arch in many of these clients. Some extrinsic factors contributing to the pathology include training surfaces, shoe wear, and poor training methods. Understanding the anatomy makes it clear why this population is at an increased risk. The plantar fascia runs from the medial tuberosity of the calcaneus and inserts into the metatarsophalangeal joints, the proximal phalanges, and the flexor tendon sheaths. The fascia is responsible for supporting the longitudinal arch of the foot and assisting in dynamic shock absorption. The attachment of the plantar fascia to the medial calcaneal tuberosity explains why patients often experience pain upon palpation of that area.
   
    Diagnosis of plantar fasciopathy is often made on a clinical basis. Due to degenerative changes and tendon thickening, the diagnosis may be made with an ultrasound as well.  Current treatment methods include rest, modalities, stretching, strengthening, manual therapy, splinting, orthotics, surgery, and more. New research is constantly being published due to the high incidence of the injury.  This review will take an in depth look at several of the available treatment techniques for plantar fasciopathy. Many of the studies we looked at included strengthening and stretching in the treatment plans along with some other intervention. Improvement was often shown in both groups, but we were unable to find any studies that specifically looked at one type of strengthening exercise compared to another. Some of the most common barefoot exercises seen in the clinic include towel scrunching and picking up marbles. Due to the biomechanical theory of the plantar fascia aiding in the support of the medial arch, it would seem logical to include strengthening of the posterior tibialis in rehabilitation. The posterior tibialis is the prime muscle for raising the medial longitudinal arch and can take stress off the plantar fascia. As noted in our previous posts, the exercise to most effectively activate the posterior tibialis is resisted forefoot adduction.

      A 2011 randomized control trial we looked at compared the effectiveness of a self-directed stretching program to a stretching program plus trigger point release therapy. The stretching only group was instructed to perform a gastroc stretch, soleus stretch, and seated plantar fascia-specific stretch. The trigger point group performed the same stretching, but also received trigger point release to the gastroc and soleus muscles. While both groups improved, the trigger point therapy group reported higher physical function, less bodily pain, and increased pressure pain thresholds for short term outcomes.   
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     Another study we reviewed compared a new calcaneal taping technique versus a sham taping group, a stretching group, and a no treatment group. The calcaneal taping technique inverted the heel to raise the medial longitudinal arch. A first piece of tape pulled the calcaneus medially. Pieces 2 and 3 followed the same pattern, overlapping 1/3 of each prior piece of tape. Piece 4 wrapped around the heel lateral to medial, supporting the arch and anchoring pieces 1-3. This 4 piece technique was considered quick and cost effective. This calcaneal taping intervention resulted in significantly greater reductions in pain compared to the sham taping, stretching, and no treatment groups.  Additionally, a study comparing Medial Arch Support to Low-Dye Taping found that both groups had improvements in pain, but the Medial Arch Support had significantly greater improvements. These interventions should be considered for short-term relief, so that the patient can be pain-free for more intense therapy or activities.
    
    A third intervention we reviewed assessed the effects of low level laser therapy in the treatment of plantar fasciitis. Laser treatments were given 3 times per week for 4 weeks with a 30mW . 83 um continuous-wave IR diode laser. The goal of the laser therapy was to alter cellular metabolism, protein synthesis, and create an immune response. The conclusions of randomized controlled evaluation found that low level laser therapy was not beneficial in the treatment of plantar heel pain. A study we looked at compared the effects of stretching and orthotics vs. e-stim, stretching, and orthotics. Both groups improved, but there was not difference between the two groups, so e-stim appears to have no additional benefit.
    
    With the recent boom in barefoot running, there has been a movement to begin incorporating barefoot or minimalist exercises/training into rehabilitation of plantar fasciitis. The theory involves placing increased forces on the intrinsic muscles of the foot, so that they can be retrained to support the arch and take stress off the plantar fascia. A study we looked at how the addition of Nike Free 5.0 shoes could affect the patients' complaints. The Nike Free 5.0 shoes offer a flexible midsole that somewhat mimics barefoot training. In the study, two groups were assigned an exercise protocol that involved balance training, stretching and strengthening exercises. One group wore conventional shoes, while the other wore the Nike Free 5.0 shoes. At the end of the study, both groups had a significant decrease in pain, the Nike Free 5.0 shoes more so. Due to the poor design, the results of this study must be looked at closely. At 24 participants, it was a small sample size and there may have been a psychological effect, since the Nike group received new shoes, while the conventional group used old shoes. Along with other factors, it is not clear if minimalist shoes can enhance rehabilitation for individuals with plantar fasciitis. It would be interesting to see the effect of more minimalist-type shoes (New Balance Minimus, Vibram Five Finger, etc.) could have on therapy in a properly done study.
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    A meta-analysis we looked at studied the effects that a shoe orthotic could have on plantar fasciitis. The study found that the addition of orthotics could decrease pain and improve function within 6-12 weeks. The control utilized night splinting, which had an improvement of pain as well, but not function. There were several issues with these findings. There was a definite lack of blinding throughout the included studies, which could have introduced some bias to the results. Also, it is unknown whether or not the patients' symptoms and function improved based off of natural healing processes or not due to the fact that there was no true control. While the theory of stress relief of the plantar fascia seems logical, there is no evidence that decreasing the mechanical forces on the plantar fascia can decrease symptoms. Also, another study found that the addition of a night splint can help improve patients' symptoms, but does not have an effect on the recurrence of the pathology.
    One of the more common interventions that is performed is stretching. A study we looked at compared the results of the standard achilles tendon stretch to a sitting plantar fascia stretch. For the plantar fascia stretch, the patient would cross his/her legs and place the affected foot on the opposite knee. The patient then grasps the toes (especially the big toe) and maximally dorsiflexes them until a stretch is felt in the foot. In the study, the patients would perform their stretch first thing in the morning and before getting up after sitting for awhile. The study found both interventions to be successful, but the plantar fascia specific stretch more so. It should be noted that the study had no true control to rule out the patients' improvements due to natural healing processes.
   
    Dry needling is still a limited treatment technique for physical therapists; however, patients can have access to acupuncture on a wider basis. One article compared two groups to see the effect of acupuncture on plantar fasciitis. Both groups received standard treatments, such as icing, stretching, intrinsic foot strengthening, and NSAIDs. One group received acupuncture, additionally. Both groups found improvements in pain. There was no difference between the two groups after 4 weeks, but the acupuncture group was slightly better after 8 weeks.
   
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    A treatment technique that is gaining popularity involves Instrument Assisted Soft Tissue Mobilization (IASTM). There are many products out there that fall under the category of IASTM: Graston Technique, ASTYM, Edge Tool, etc. The theory is generally the same behind them in that, through use of the tools, a healing inflammatory phase can be initiated by stimulating blood flow, nutrients, and fibroblasts to the area. Through proliferation of the fibroblasts, healing and formation of collagen can begin. The soft tissue mobilization can additionally aide in reorganization of the collagen fibers to proper orientation. This study in particular was a preliminary look at Graston Technique, discussing the theory, protocol, initial evidence, and some case studies. As plantar fasciitis is a soft tissue pathology, IASTM could have useful implications for patients with this disorder. When further research is performed on the subject, it may be found that IASTM has a very important place in treating these patients.
References:
Abd El Salam MS, Abd Elhafz YN. "Low-dye taping versus medial arch support in managing pain and pain-related disability in patients with plantar fasciitis." Foot Ankle Spec. 2011 Apr;4(2):86-91. Web. 10/13/12.

Bassford, Jeffrey. "A Randomized Controlled Evaluation of Low Level Laser Therapy: Plantar Fasciitis." Arch Phys Med Rehabil. 79. (1998): n. page. Web. 8 Oct. 2012.

Beyzadeoğlu T, Gökçe A, Bekler H. "[The effectiveness of dorsiflexion night splint added to conservative treatment for plantar fasciitis]." Acta Orthop Traumatol Turc. 2007;41(3):220-4. Web. 10/13/12.
Digiovanni BF
, Nawoczenski DA, Malay DP, Graci PA, Williams TT, Wilding GE, Baumhauer JF. "Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up." J Bone Joint Surg Am. 2006 Aug;88(8):1775-81. Web. 10/12/12.

Hammer, WI. "The effect of mechanical load on degenerated soft tissue." J body Mov Ther. 12.3 (2008): 246-256. Web. 8 Oct. 2012.

Hyland, Matthew. "Randomized Control Trial of Calcaneal Taping, Sham Taping, and Plantar Fascia Stretching for the Short-term Management of Plantar Heel Pain." Journal of Orthopaedic and Sports Physical Therapy. 36.6 (2006): n. page. Web. 8 Oct. 2012.

Karagounis P, Tsironi M, Prionas G, Tsiganos G, Baltopoulos P. "Treatment of plantar fasciitis in recreational athletes: two different therapeutic protocols." Foot Ankle Spec. 2011 Aug;4(4):226-34. Web. 10/13/12.

Lee SY, McKeon P, Hertel J. "Does the use of orthoses improve self-reported pain and function measures in patients with plantar fasciitis? A meta-analysis." Phys Ther Sport. 2009 Feb;10(1):12-8. Web. 10/10/2012.

Renan-Ording, Romulo. "Effectiveness of Myofascial Trigger Point Manual Therapy Combined with a Self-stretching Protocol for the Management of Plantar Heel Pain: A Randomized Control Trial." Journal of Orthopedic and Sports Physical Therapy. 41.2 (2011): 43-51. Web. 8 Oct. 2012.

Ryan, M, S Fraser, K McDonald, and J Taunton. "Examining the degree of pain reduction using a multielement exercise model with a conventional training shoe versus an ultraflexible training shoe for treating plantar fasciitis." Phys Sportsmed. 37.4 (2009): 67-84. Web. 10 Oct. 2012.

Stratton M, McPoil TG, Cornwall MW, Patrick K. "Use of low-frequency electrical stimulation for the treatment of plantar fasciitis." J Am Podiatr Med Assoc. 2009 Nov-Dec;99(6):481-8. Web. 10/13/12.
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      • Seated Forward Flexion Test
      • SIJ Compression/Distraction Test
      • Slump Test
      • Sphinx Test
      • Spine Rotators & Multifidus Test
      • Squish Test
      • Standing Forward Flexion Test
      • Straight Leg Raise Test
      • Supine to Long Sit Test
    • Shoulder >
      • Active Compression Test
      • Anterior Apprehension
      • Biceps Load Test II
      • Drop Arm Sign
      • External Rotation Lag Sign
      • Hawkins-Kennedy Impingement Sign
      • Horizontal Adduction Test
      • Internal Rotation Lag Sign
      • Jobe Test
      • Ludington's Test
      • Neer Test
      • Painful Arc Sign
      • Pronated Load Test
      • Resisted Supination External Rotation Test
      • Speed's Test
      • Posterior Apprehension
      • Sulcus Sign
      • Thoracic Outlet Tests >
        • Adson's Test
        • Costoclavicular Brace
        • Hyperabduction Test
        • Roos (EAST)
      • Yergason's Test
    • Elbow >
      • Biceps Squeeze Test
      • Chair Sign
      • Cozen's Test
      • Elbow Extension Test
      • Medial Epicondylalgia Test
      • Mill's Test
      • Moving Valgus Stress Test
      • Push-up Sign
      • Ulnar Nerve Compression Test
      • Valgus Stress Test
      • Varus Stress Test
    • Wrist/Hand >
      • Allen's Test
      • Carpal Compression Test
      • Finkelstein Test
      • Phalen's Test
      • Reverse Phalen's Test
    • Hip >
      • Craig's Test
      • Dial Test
      • FABER Test
      • FAIR Test
      • Fitzgerald's Test
      • Hip Quadrant Test
      • Hop Test
      • Labral Anterior Impingement Test
      • Labral Posterior Impingement Test
      • Long-Axis Femoral Distraction Test
      • Noble Compression Test
      • Percussion Test
      • Sign of the Buttock
      • Trendelenburg Test
    • Knee >
      • Anterior Drawer Test
      • Dial Test (Tibial Rotation Test)
      • Joint Line Tenderness
      • Lachman Test
      • McMurray Test
      • Noble Compression Test
      • Pivot-Shift Test
      • Posterior Drawer Test
      • Posterior Sag Sign
      • Quad Active Test
      • Thessaly Test
      • Valgus Stress Test
      • Varus Stress Test
    • Foot/Ankle >
      • Anterior Drawer
      • Calf Squeeze Test
      • External Rotation Test
      • Fracture Screening Tests
      • Impingement Sign
      • Navicular Drop Test
      • Squeeze Test
      • Talar Tilt
      • Tarsal Tunnel Syndrome Test
      • Test for Interdigital Neuroma
      • Windlass Test